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Calpin GG, Davey MG, Donlon NE. Management of early oesophageal cancer: An overview. World J Gastrointest Surg 2024; 16:1255-1258. [PMID: 38817272 PMCID: PMC11135312 DOI: 10.4240/wjgs.v16.i5.1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/29/2024] [Accepted: 04/19/2024] [Indexed: 05/23/2024] Open
Abstract
The incidence of esophageal cancer, namely the adenocarcinoma subtype, continues to increase exponentially on an annual basis. The indolent nature of the disease renders a significant proportion inoperable at first presentation, however, with the increased utilisation of endoscopy, many early lesions are now being identified which are suitable for endotherapeutic approaches. This article details the options available for dealing with early esophageal cancer by endoscopic mean obviating the need for surgery thereby avoiding the potential morbidity and mortality of such intervention.
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Affiliation(s)
- Gavin G Calpin
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin D2, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin D2, Ireland
| | - Noel E Donlon
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin D09V2N0, Ireland
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2
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Mohapatra S, Al Ghamdi SS, Charilaou P, Lopimpisuth C, Das A, Ngamruengphong S. Predictors for lymph node metastasis and survival of patients with T1b esophageal adenocarcinoma treated with surgery and endoscopic therapy: an analysis of the Surveillance, Epidemiology, and End Results database. Gastrointest Endosc 2024:S0016-5107(24)03190-0. [PMID: 38734257 DOI: 10.1016/j.gie.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/22/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND AND AIMS Limited data exist regarding the long-term outcomes of endoscopic therapy (ET) with or without chemoradiation therapy (CRT) for T1b esophageal adenocarcinoma (EAC). Our aim was to identify the risk factors for lymph node metastasis (LNM) in T1b EAC and assess how the chosen treatment modality affects overall survival (OS) and cancer-specific survival (CSS). METHODS We analyzed patients with histologically confirmed T1b EAC diagnosed between 2004 and 2018 using the Surveillance, Epidemiology, and End Results database. Focusing on T1bN0M0 staging, the patients were divided into 2 groups (ET [n = 174] and surgery [n = 769]), and OS and CSS rates were calculated. RESULTS Of 1418 patients with T1b EAC, 228 cases (16.1%) exhibited LNM at diagnosis. Notable risk factors for LNM included poorly differentiated tumor and lesion size ≥20 mm. For T1bN0M0 cases, ET was commonly performed from 2009 to 2018 (odds ratio [OR], 4.3), especially for patients aged ≥65 years (OR, 3.1) with tumor size <20 mm (OR, 2.3). During the median 50 months of follow-up, age ≥65 years (hazard ratio [HR], 1.9), ET (HR, 1.5), and CRT (HR, 1.4) were associated with poorer OS. Factors linked to decreased CSS were age ≥65 years (subhazard ratio [SHR], 1.6), poorly differentiated tumors (SHR, 1.5), and CRT (SHR, 1.5). CONCLUSIONS In T1b EAC, tumor size ≥20 mm and poor differentiation are notable risk factors for LNM. ET exhibited comparable CSS outcomes to surgery for carefully selected T1bN0M0 lesions. CRT did not provide additional survival benefit for these lesions; however, large-scale studies are required to validate this finding.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Sarah S Al Ghamdi
- Department of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paris Charilaou
- Department of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill-Cornell Medical College, New York, New York, USA
| | - Chawin Lopimpisuth
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Amit Das
- Department of Computer Science, Dartmouth College, Hanover, New Hampshire, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA.
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3
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Leclercq P, Bisschops R, Bergman JJGHM, Pouw RE. Management of high risk T1 esophageal adenocarcinoma following endoscopic resection. Best Pract Res Clin Gastroenterol 2024; 68:101882. [PMID: 38522880 DOI: 10.1016/j.bpg.2024.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 03/26/2024]
Abstract
High-risk T1 esophageal adenocarcinoma (HR-T1 EAC) is defined as T1 cancer, with one or more of the following histological criteria: submucosal invasion, poorly or undifferentiated cancer, and/or presence of lympho-vascular invasion. Esophagectomy has long been the only available treatment for these HR-T1 EACs and was considered necessary because of a presumed high risk of lymph node metastases up to 46%. However, endoscopic submucosal disscection have made it possible to radically remove HR-T1 EAC, irrespective of size, while leaving the esophageal anatomy intact. Parallel to this development, new publications demonstrated that the risk of lymph node metastases for HR-T1 EAC may be even <24%. Therefore, indications for endoscopic treatment of HR-T1 EAC are being reconsidered and current research aims at finding the optimal management strategy for this indication, where watchful waiting may proof to be an acceptable strategy in selected patients. In this review, we will discuss the latest developments in this field.
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Affiliation(s)
- Philippe Leclercq
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Raf Bisschops
- Departement of Gastroenterology, Universitair Ziekenhuis Leuven, 49 Herestraat, 3000, LEUVEN, Belgium.
| | - Jacques J G H M Bergman
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
| | - Roos E Pouw
- Dept. of Gastroenterology and Hepatology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, 1081, HV, Netherlands.
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4
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Liu H, Meng J. Comparison of LNM and survival in T1 stage esophageal cancer patients based on histological classification: A large population-based study. Medicine (Baltimore) 2022; 101:e32143. [PMID: 36595761 PMCID: PMC9794276 DOI: 10.1097/md.0000000000032143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Limited evidence and contradictory results have been reported regarding the impact of squamous cell carcinoma (SCC) and adenocarcinoma (AC) classification on lymph node metastasis (LNM) and prognosis in esophageal cancer (EC). We aimed to compare 2 histology types in terms of LNM and prognosis using a comprehensive statistical analysis of a large population. The Surveillance, Epidemiology, and End Results (SEER) database was used to extract patient information. Univariate and multivariate logistic or Cox regression, a multivariate competing risk model and propensity score matching (PSM) were used to explore the association between LNM or survival and the 2 histology types. Information for 4764 patients, including 1712 SCC and 3052 AC patients, was extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate logistic regression analysis revealed a correlation between LNM and histology (odds ratio [OR] = 0.654, P = .037). We found that patients with AC had a better prognosis than SCC patients through both the multivariate Cox regression (hazard ratio [HR] = 0.866) and the multivariate competing risk model (subdistribution hazard ratio [SHR] = 0.704). However, no positive relation was found between LNM and histology type (P = .844) based on propensity score matching (PSM), and the prognosis remained poorer for the patients with SCC (P < .001). T1-stage EC with a histology of SCC may have a comparable risk of LNM as the AC type, while SCC has a poorer prognosis than the AC type.
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Affiliation(s)
- Hui Liu
- Department of Gastroenterology, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
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5
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Zhu TY, Deng XM, Wang GJ, Gao BL, Li RX, Wang JT. Comparison of short-term surgical outcomes between complete mesenteric resection and traditional transhiatal laparoscopic surgery for Siewert type II/III esophagogastric junction adenocarcinoma. Langenbecks Arch Surg 2022; 407:3811-3818. [PMID: 36214868 DOI: 10.1007/s00423-022-02676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 09/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To explore the effectiveness and safety of laparoscopic transhiatal complete mesenteric resection (CME) surgery compared with those of the traditional laparoscopic transhiatal approach in the treatment of Siewert II/III adenocarcinoma of the esophagogastric junction (AEG). MATERIALS AND METHODS Ninety-nine patients with Siewert type II/III AEG were enrolled and divided into two groups: the laparoscopic CME transhiatal approach (CEM-TH, n = 61) group and traditional laparoscopic transhiatal (TH, n = 38) group. Intraoperative and postoperative clinical data of both groups were analyzed. RESULTS The laparoscopic trasihiatal surgery was technically successful in all patients. The surgical time, intraoperative bleeding, and hospital stay were all significantly (P < 0.05) reduced in the CME-TH group compared with those in the TH group. The levels of white blood cells on postoperative day (POD) 1 and 5, postoperative CRP on POD 3 and 5, and postoperative PCT were significantly (P < 0.05) lower while lymph nodes were harvested significantly (P < 0.05) more in the CME-TH group than in the TH group. Complications were not significantly (P > 0.05) different between two groups. No death occurred within 90 days. CONCLUSION The CME theory could be safely and effectively applied laparoscopically to treat patients with Siewert II/III AEG. Mesogastrium and lower mesoesophagus can be completely resected together with the tumor, lymph nodes, adipose tissue, and blood vessels as an "intact package," leading to better short-term outcomes.
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Affiliation(s)
- Tian-Yu Zhu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe, Zhengzhou, 450052, China
| | - Xiu-Mei Deng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe, Zhengzhou, 450052, China.
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe, Zhengzhou, 450052, China
| | - Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe, Zhengzhou, 450052, China
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6
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Boshier PR, Swaray A, Vadhwana B, O’Sullivan A, Low DE, Hanna GB, Peters CJ. Systematic review and validation of clinical models predicting survival after oesophagectomy for adenocarcinoma. Br J Surg 2022; 109:418-425. [PMID: 35233634 PMCID: PMC10364693 DOI: 10.1093/bjs/znac044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/10/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Oesophageal adenocarcinoma poses a significant global health burden, yet the staging used to predict survival has limited ability to stratify patients by outcome. This study aimed to identify published clinical models that predict survival in oesophageal adenocarcinoma and to evaluate them using an independent international multicentre dataset. METHODS A systematic literature search (title and abstract) using the Ovid Embase and MEDLINE databases (from 1947 to 11 July 2020) was performed. Inclusion criteria were studies that developed or validated a clinical prognostication model to predict either overall or disease-specific survival in patients with oesophageal adenocarcinoma undergoing surgical treatment with curative intent. Published models were validated using an independent dataset of 2450 patients who underwent oesophagectomy for oesophageal adenocarcinoma with curative intent. RESULTS Seventeen articles were eligible for inclusion in the study. Eleven models were suitable for testing in the independent validation dataset and nine of these were able to stratify patients successfully into groups with significantly different survival outcomes. Area under the receiver operating characteristic curves for individual survival prediction models ranged from 0.658 to 0.705, suggesting poor-to-fair accuracy. CONCLUSION This study highlights the need to concentrate on robust methodologies and improved, independent, validation, to increase the likelihood of clinical adoption of survival predictions models.
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Affiliation(s)
- Piers R Boshier
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alison Swaray
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bhamini Vadhwana
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Arun O’Sullivan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Centre, Seattle, Washington, USA
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
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7
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Gotink AW, van de Ven SEM, Ten Kate FJC, Nieboer D, Suzuki L, Weusten BLAM, Brosens LAA, van Hillegersberg R, Alvarez Herrero L, Seldenrijk CA, Alkhalaf A, Moll FCP, Schoon EJ, van Lijnschoten I, Tang TJ, van der Valk H, Nagengast WB, Kats-Ugurlu G, Plukker JTM, Houben MHMG, van der Laan JS, Pouw RE, Bergman JJGHM, Meijer SL, van Berge Henegouwen MI, Wijnhoven BPL, de Jonge PJF, Doukas M, Bruno MJ, Biermann K, Koch AD. Individual risk calculator to predict lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study. Endoscopy 2022; 54:109-117. [PMID: 33626582 DOI: 10.1055/a-1399-4989] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC. METHODS A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic. RESULTS 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86). CONCLUSIONS A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice.
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Affiliation(s)
- Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Fiebo J C Ten Kate
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.,Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lucia Suzuki
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, Pathology DNA, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Hans van der Valk
- Department of Pathology, Ijselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, the Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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8
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Kohli DR, Sharma P. Estimating risk of metastatic disease in T1b esophageal adenocarcinoma: incremental progress but gaps remain. Endoscopy 2022; 54:118-119. [PMID: 34404108 DOI: 10.1055/a-1499-7516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Divyanshoo R Kohli
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri, United States
| | - Prateek Sharma
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri, United States.,Gastroenterology, University of Kansas School of Medicine, Kansas City, Kansas, United States
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9
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van de Ven SEM, Suzuki L, Gotink AW, Ten Kate FJC, Nieboer D, Weusten BLAM, Brosens LAA, van Hillegersberg R, Alvarez Herrero L, Seldenrijk CA, Alkhalaf A, Moll FCP, Curvers W, van Lijnschoten IG, Tang TJ, van der Valk H, Nagengast WB, Kats-Ugurlu G, Plukker JTM, Houben MHMG, van der Laan JS, Pouw RE, Bergman JJGHM, Meijer SL, van Berge Henegouwen MI, Wijnhoven BPL, de Jonge PJF, Doukas M, Bruno MJ, Biermann K, Koch AD. Lymphovascular invasion quantification could improve risk prediction of lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma. United European Gastroenterol J 2021; 9:1066-1073. [PMID: 34609076 PMCID: PMC8598963 DOI: 10.1002/ueg2.12151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/16/2021] [Accepted: 08/05/2021] [Indexed: 01/08/2023] Open
Abstract
Aim To quantify lymphovascular invasion (LVI) and to assess the prognostic value in patients with pT1b esophageal adenocarcinoma. Methods In this nationwide, retrospective cohort study, patients were included if they were treated with surgery or endoscopic resection for pT1b esophageal adenocarcinoma. Primary endpoint was the presence of metastases, lymph node metastases, or distant metastases, in surgical resection specimens or during follow‐up. A prediction model to identify risk factors for metastases was developed and internally validated. Results 248 patients were included. LVI was distributed as follows: no LVI (n = 196; 79.0%), 1 LVI focus (n = 16; 6.5%), 2–3 LVI foci (n = 21; 8.5%) and ≥4 LVI foci (n = 15; 6.0%). Seventy‐eight patients had metastases. The risk of metastases was increased for tumors with 2–3 LVI foci [subdistribution hazard ratio (SHR) 3.39, 95% confidence interval (CI) 2.10–5.47] and ≥4 LVI foci (SHR 3.81, 95% CI 2.37–6.10). The prediction model demonstrated a good discriminative ability (c‐statistic 0.81). Conclusion The risk of metastases is higher when more LVI foci are present. Quantification of LVI could be useful for a more precise risk estimation of metastases. This model needs to be externally validated before implementation into clinical practice.
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Affiliation(s)
- Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Lucia Suzuki
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Fiebo J C Ten Kate
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.,Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, Pathology DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Wouter Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Hans van der Valk
- Department of Pathology, Ijselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, The Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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10
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Oetzmann von Sochaczewski C, Haist T, Pauthner M, Mann M, Braun S, Ell C, Lorenz D. Infiltration Depth is the Most Relevant Risk Factor for Overall Metastases in Early Esophageal Adenocarcinoma. World J Surg 2020; 44:1192-1199. [PMID: 31853591 DOI: 10.1007/s00268-019-05291-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Research in early esophageal adenocarcinoma focused on prediction of lymph node metastases in order to stratify patients for endoscopic treatment instead of esophagectomy. Although distant metastases were described in rates of up to 13% of patients within a follow-up of 3 years, their prediction has been neglected so far. METHODS In a secondary analysis, a cohort of 217 patients (53 T1a and 164 T1b) treated by esophagectomy was analyzed for histopathological risk factors. Their ability to predict the combination of lymph node metastases at surgery as well as metachronous locoregional and distant metastases (overall metastatic rate) was assessed by uni- and multivariate logistic regression analysis. RESULTS Tumor invasion depth was correlated with both lymph node metastases at surgery (τ = 0.141; P = .012), tumor recurrences (τ = 0.152; P = .014), and distant metastases (τ = 0.122; P = 0.04). Multivariate analysis showed an odds ratio of 1.31 (95% CI 1.02-1.67; P = .033) per increasing tumor invasion depth and of 3.5 (95% CI 1.70-6.56; P < .001) for lymphovascular invasion. The pre-planned subgroup analysis in T1b tumors demonstrated an even lower predictive ability of lymphovascular invasion with an odds ratio of 2.5 (95% CI 1.11-5.65; P = 0.028), whereas the predictive effect of sm2 (odds ratio 3.44; 95% CI 1.00-11.9; P = 0.049) and sm3 (odds ratio 3.44; 95% CI 1.00-11.9; P = 0.049) tumor invasion depth was similar. CONCLUSIONS The present report demonstrates the insufficient risk prediction of histopathologic risk factors for the overall metastatic rate.
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Affiliation(s)
| | - Thomas Haist
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Michael Pauthner
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Markus Mann
- Department of Surgery I, Sana Klinikum Offenbach, Offenbach, Germany
| | - Susanne Braun
- Institute of Pathology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Christian Ell
- Department of Internal Medicine II, Sana Klinikum Offenbach, Offenbach, Germany
| | - Dietmar Lorenz
- Department of Surgery I, Klinikum Darmstadt, Grafenstraße 9, 64283, Darmstadt, Germany.
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11
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Sihag S, De La Torre S, Hsu M, Nobel T, Tan KS, Gerdes H, Shah P, Bains M, Jones DR, Molena D. Defining low-risk lesions in early-stage esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2020; 162:1272-1279. [PMID: 33334599 DOI: 10.1016/j.jtcvs.2020.10.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE As endoscopic approaches become more widely used to treat early-stage esophageal cancer, reliably identifying patients with less-aggressive tumors is paramount. We sought to identify risk factors for recurrence in patients with completely resected T1 esophageal adenocarcinoma. METHODS We retrospectively analyzed a single-institutional database for all patients with completely resected pathologic T1 esophageal adenocarcinoma (1996-2016). Risk factors for recurrence were identified using competing-risk regression methods. Risk stratification was performed on the basis of known preoperative clinicopathologic factors; this model's discriminative power for overall survival was evaluated using a Cox proportional hazards model. RESULTS Of 243 patients, 32 experienced recurrence. At a median follow-up among survivors of 4 years (range, 0.05-19 years), the 5-year cumulative incidence of recurrence was 15%, and median time to recurrence was 2 years (range, 0.26-6.13 years). On univariable analysis, submucosal invasion, N1 disease, poor differentiation, tumor length, lymphovascular invasion, and multicentricity were significantly associated with recurrence. On multivariable analysis, N1 disease (hazard ratio, 2.93; 95% confidence interval, 1.17-7.34; P = .022) and tumor length (hazard ratio, 1.44; 95% confidence interval, 1.12-1.86; P = .004) were independently associated with recurrence. Risk stratification showed that patients without lymphovascular invasion and a with median tumor length of 0.8 cm (range, 0.10-1.70 cm) had a <10% risk of recurrence and improved survival. CONCLUSIONS Pathologic T1 tumors have a 5-year cumulative incidence of recurrence of 15%. Nodal involvement and tumor length were independent risk factors for recurrence, whereas tumors <2 cm in length without lymphovascular invasion were associated with a low risk of recurrence.
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Affiliation(s)
- Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Sergio De La Torre
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tamar Nobel
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hans Gerdes
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Pari Shah
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Manjit Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Deng W, Jethwa KR, Gonuguntla K, Liao Z, Yoon HH, Murphy MB, Haddock MG, Hallemeier CL, Lin SH. Multi-institutional Evaluation of Curative Intent Chemoradiotherapy for Patients With Clinical T1N0 Esophageal Adenocarcinoma. Adv Radiat Oncol 2020; 5:951-958. [PMID: 33083658 PMCID: PMC7557140 DOI: 10.1016/j.adro.2020.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/04/2019] [Accepted: 03/31/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the safety and efficacy of definitive chemoradiotherapy (CRT) for patients with clinical T1N0M0 esophageal adenocarcinoma. Methods and Materials This was a retrospective study of patients with clinical T1N0 adenocarcinoma of the esophagus treated with curative-intent CRT between 2004 and 2017 at 2 tertiary care centers. Patients received CRT instead of esophagectomy owing to medical comorbidities or patient preference. Toxicities were evaluated according to Common Terminology Criteria for Adverse Events version 4.03. The Kaplan-Meier method was used to estimate overall, progression-free, and disease-specific survivals. Results Twenty-eight patients were included for analysis. Median age was 76 years (range 55-90). The majority of patients were male (93%) and had a history of Barrett’s esophagus (71%). Tumor characteristics included distal esophagus location (93%), clinical stage T1b (86%), and median length of 2 cm (range, 1-9). Prior endoscopic resection was performed in 57%. The median follow-up was 44 months (range, 4-146). The acute grade 3 adverse events were observed in 7 patients (25%). One patient died of complications potentially related to chemoradiation. Eight patients (29%) had disease progression at a median of 7.6 months after CRT. First site of progression was local only (14%), local and regional (11%), or distant (4%). Salvage locally directed treatment was performed in 3 of 4 patients with local-only recurrence. The 3-year overall survival, progression-free, and disease-specific rates were 78%, 62%, and 81%, respectively. Conclusion CRT is a safe and effective curative treatment strategy for select patients with clinical T1N0M0 esophageal adenocarcinoma.
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Affiliation(s)
- Wei Deng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Harry H Yoon
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | | | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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13
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Zhu LH, Yao J, Wu T, Wang Y, Wang CW, Xue CQ, Wu LG, Fan XW, Wu CY. Risk of Recurrence and Metastasis for Patients with T1N0M0 Esophageal Carcinoma Who Achieve Completed Resection via Endoscopic Submucosal Resection: Evidence for the Appropriateness of the Watch and Wait Follow-Up Strategy. Cancer Manag Res 2020; 12:2427-2435. [PMID: 32308479 PMCID: PMC7135163 DOI: 10.2147/cmar.s227959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/22/2020] [Indexed: 01/03/2023] Open
Abstract
Purpose Endoscopic submucosal dissection (ESD) is a widely performed procedure for esophageal carcinoma when the depth of invasion reaches the epithelium and lamina propria. However, ESD for esophageal carcinoma with depth of invasion exceeding the muscularis mucosa is controversial. This study aimed to evaluate the long-term outcomes of ESD for T1N0M0 (tumor invading the mucosa and submucosa [T1], no regional lymph node metastasis [N0], no distant metastasis [M0]) esophageal cancer. Patients and Methods Esophageal cancer was evaluated via pathology and computed tomography (CT) in consecutive patients with negative margin and without additional therapy. A total of 84 patients were included. The mean follow-up time was 42 (range, 9-99) months. Results No recurrence and metastasis were detected in the M1 and M2 group. The 5-year locoregional recurrence rate and distant metastasis rate were 4.2% and 5.6% for the M3 group and were 0% and 1.4% for the SM group, respectively. The 3- and 5-year overall survival were 94.4% (M1+M2 group, 95.0%; M3 group, 95.0%; SM group, 92.9%) and 80.9% (M1+M2 group, 95.0%; M3 group, 95.0%; SM group, 92.9%). Meanwhile, the 3- and 5-year disease-specific survival rates were 100% (M1+M2 group, 100%; M3 group, 100%; SM group, 100%) and 90.8% (M1+M2 group, 100%; M3 group, 90.0%; SM group, 85.7%). The major complications were postoperative strictures, most of which were grade 1-2. In total, two (4.8%) and one (1.2%) patient developed grade 3 and 5 late esophageal strictures, respectively. Conclusion ESD complete resection yields low recurrence and metastasis rates in early esophageal cancer (T1N0M0). Thus, additional treatment is not necessary, and a watch and wait strategy may be reasonable.
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Affiliation(s)
- Li-Hua Zhu
- Department of Radiation Oncology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Jun Yao
- Department of Gastroenterology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Ting Wu
- Department of Pathology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Yan Wang
- Department of Radiation Oncology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Chen-Wei Wang
- Department of Radiation Oncology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Chun-Quan Xue
- Department of Radiation Oncology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Li-Guang Wu
- Department of Radiation Oncology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
| | - Xing-Wen Fan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, People's Republic of China
| | - Chao-Yang Wu
- Department of Radiation Oncology, The People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu Province 212003, People's Republic of China
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14
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Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C. Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice. World J Meta-Anal 2019; 7:406-417. [DOI: 10.13105/wjma.v7.i9.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.
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Affiliation(s)
| | - Elisabeth Silver
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Aaron Oh
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Julian A Abrams
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Joshua R Sonett
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
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15
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Abstract
Traditionally, early esophageal cancer (i.e., cancer limited to the mucosa or superficial submucosa) was managed surgically; the gastroenterologist's role was primarily to diagnose the tumor. Over the last decade, advances in endoscopic imaging, ablation, and resection techniques have resulted in a paradigm shift-diagnosis, staging, treatment, and surveillance are within the endoscopist's domain. Yet, there are few reviews that provide a focused, evidence-based approach to early esophageal cancer, and highlight areas of controversy for practicing gastroenterologists. In this manuscript, we will discuss the following: (1) utility of novel endoscopic technologies to identify high-grade dysplasia and early esophageal cancer, (2) role of endoscopic resection and imaging to stage early esophageal cancer, (3) endoscopic therapies for early esophageal cancer, and (4) indications for surgical and multidisciplinary management.
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16
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Barrett's adenocarcinoma with esophageal varices successfully treated by endoscopic submucosal dissection with direct varices coagulation. Clin J Gastroenterol 2019; 13:178-181. [PMID: 31559540 DOI: 10.1007/s12328-019-01048-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/17/2019] [Indexed: 12/27/2022]
Abstract
A 67-year-old Japanese man with alcoholic cirrhosis underwent esophagogastroduodenoscopy (EGD), which revealed a 15-mm elevated lesion on the esophagogastric junction (EGJ). Endoscopic findings suggested that the lesion was an intramucosal cancer present on the esophageal varices. The location of the lesion at EGJ caused difficulties in endoscopic injection sclerotherapy and endoscopic variceal ligation for esophageal varices before esophageal endoscopic submucosal dissection (ESD). Direct varices coagulation treatment was therefore selected during ESD. Coagulation of bared varices with hemostatic forceps after mucosal incision enabled performing ESD without serious bleeding. 2 months afterwards, the patient underwent EGD, with no esophageal varices or carcinoma recurrence. Direct varices coagulation was effective for ESD of Barrett adenocarcinoma with esophageal varices.
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17
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Hasson RM, Phillips JD. Editorial "Discrepancy Between the Clinical and Final Pathological Findings of Lymph Node Metastasis in Superficial Esophageal Cancer". Ann Surg Oncol 2019; 26:2662-2664. [PMID: 31228137 DOI: 10.1245/s10434-019-07501-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Rian M Hasson
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Joseph D Phillips
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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18
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Ongoing Challenges with Clinical Assessment of Nodal Status in T1 Esophageal Adenocarcinoma. J Am Coll Surg 2019; 229:366-373. [PMID: 31108196 DOI: 10.1016/j.jamcollsurg.2019.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) has emerged as an esophageal-preserving treatment for T1 esophageal adenocarcinoma (EAC); however, only patients with negligible risk of lymph node metastasis (LNM) are eligible. Reliable clinical diagnostic tools for LNM are lacking, as such, several risk assessment scores have been developed. The purpose of this study was to externally validate 2 previously published risk scores (Lee and Weksler) for clinical prediction of LNM in T1 EAC patients. METHODS In adherence with the Lee and Weksler scores, esophagectomy patients with pathologic T1 EAC were identified. Sub-analysis was performed in patients with clinical T1 based on EMR. Predictive accuracy of the scores was evaluated by calculating the area under the curve of the receiver operating characteristic curve and calibration plots. The areas under the curves were compared using Venkatraman's test for paired receiver operating characteristic curves. RESULTS Of 233 patients identified who met study criteria for external validation, 3 T1a and 32 T1b patients had LNM. The receiver operating characteristic curves demonstrated comparable high predictive and discriminatory capabilities with areas under the curves of 0.832 and 0.824 for the Lee and Weksler scores, respectively (p = 0.750). Results were more variable for the EMR cohort. Based on the risk thresholds defined by each score, the false-positive rate compared against the pathologic LNM status were 73% and 56% for Lee and Weksler, with 3% false negatives in the latter. On EMR, the false-positive rates were 70% and 50% for Lee and Weksler, with no false negatives. CONCLUSIONS Both scoring systems demonstrated good discriminatory ability and predictive accuracy for LNM, but the defined thresholds resulted in a high false-positive rate. A better scoring system based on clinical characteristics is needed to better identify patients with local disease.
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19
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Ramay FH, Vareedayah AA, Visrodia K, Iyer PG, Wang KK, Eluri S, Shaheen NJ, Reddy R, Martin LW, Greenwald BD, Edwards MA. What Constitutes Optimal Management of T1N0 Esophageal Adenocarcinoma? Ann Surg Oncol 2019; 26:714-731. [DOI: 10.1245/s10434-018-07118-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/27/2022]
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20
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Ishihara R, Goda K, Oyama T. Endoscopic diagnosis and treatment of esophageal adenocarcinoma: introduction of Japan Esophageal Society classification of Barrett's esophagus. J Gastroenterol 2019; 54:1-9. [PMID: 29961130 PMCID: PMC6314977 DOI: 10.1007/s00535-018-1491-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/27/2018] [Indexed: 02/04/2023]
Abstract
Endoscopic surveillance of Barrett's esophagus has become a foundation of the management of esophageal adenocarcinoma (EAC). Surveillance for Barrett's esophagus commonly involves periodic upper endoscopy with biopsies of suspicious areas and random four-quadrant biopsies. However, targeted biopsies using narrow-band imaging can detect more dysplastic areas and thus reduce the number of biopsies required. Several specific mucosal and vascular patterns characteristic of Barrett's esophagus have been described, but the proposed criteria are complex and diverse. Simpler classifications have recently been developed focusing on the differentiation between dysplasia and non-dysplasia. These include the Japan Esophageal Society classification, which defines regular and irregular patterns in terms of mucosal and vascular shapes. Cancer invasion depth is diagnosed by endoscopic ultrasonography (EUS); however, a meta-analysis of EUS staging of superficial EAC showed favorable pooled values for mucosal cancer staging, but unsatisfactory diagnostic results for EAC at the esophagogastric junction. Endoscopic resection has recently been suggested as a more accurate staging modality for superficial gastrointestinal cancers than EUS. Following endoscopic resection for gastrointestinal cancers, the risk of metastasis can be evaluated based on the histology of the resected specimen. European guidelines describe endoscopic resection as curative for well- or moderately differentiated mucosal cancers without lymphovascular invasion, and these criteria might be extended to lesions invading the submucosa (≤ 500 μm), i.e., to low-risk, well- or moderately differentiated tumors without lymphovascular involvement, and < 3 cm. These criteria were confirmed by a recent study in Japan.
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Affiliation(s)
- Ryu Ishihara
- grid.489169.bDepartment of Gastrointestinal Oncology, Osaka International Cancer Institute, 1-69 Otemae 3-chome, Chuo-ku, Osaka, 541-8567 Japan
| | - Kenichi Goda
- 0000 0000 8864 3422grid.410714.7Digestive Disease Centre, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Tsuneo Oyama
- 0000 0000 8962 7491grid.416751.0Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
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21
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Kitagawa Y, Uno T, Oyama T, Kato K, Kato H, Kawakubo H, Kawamura O, Kusano M, Kuwano H, Takeuchi H, Toh Y, Doki Y, Naomoto Y, Nemoto K, Booka E, Matsubara H, Miyazaki T, Muto M, Yanagisawa A, Yoshida M. Esophageal cancer practice guidelines 2017 edited by the Japan esophageal society: part 2. Esophagus 2019; 16:25-43. [PMID: 30171414 PMCID: PMC6510875 DOI: 10.1007/s10388-018-0642-8] [Citation(s) in RCA: 305] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Yuko Kitagawa
- grid.26091.3c0000 0004 1936 9959Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Takashi Uno
- grid.136304.30000 0004 0370 1101Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsuneo Oyama
- grid.416751.00000 0000 8962 7491Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
| | - Ken Kato
- grid.272242.30000 0001 2168 5385Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Kato
- grid.411582.b0000 0001 1017 9540Department of Gastrointestinal Tract Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hirofumi Kawakubo
- grid.26091.3c0000 0004 1936 9959Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Osamu Kawamura
- grid.411887.30000 0004 0595 7039Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Gunma Japan
| | - Motoyasu Kusano
- grid.411887.30000 0004 0595 7039Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Gunma Japan
| | - Hiroyuki Kuwano
- grid.256642.10000 0000 9269 4097Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma Japan
| | - Hiroya Takeuchi
- grid.505613.40000 0000 8937 6696Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yuichiro Doki
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka Japan
| | - Yoshio Naomoto
- grid.415086.e0000 0001 1014 2000Department of General Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kenji Nemoto
- grid.268394.20000 0001 0674 7277Department of Radiation Oncology, Yamagata University School of Medicine, Yonezawa, Japan
| | - Eisuke Booka
- grid.26091.3c0000 0004 1936 9959Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Hisahiro Matsubara
- grid.136304.30000 0004 0370 1101Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tatsuya Miyazaki
- grid.256642.10000 0000 9269 4097Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma Japan
| | - Manabu Muto
- grid.411217.00000 0004 0531 2775Department of Clinical Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Akio Yanagisawa
- grid.272458.e0000 0001 0667 4960Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Yoshida
- grid.411731.10000 0004 0531 3030Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
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22
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Zhang Y, Ding H, Chen T, Zhang X, Chen WF, Li Q, Yao L, Korrapati P, Jin XJ, Zhang YX, Xu MD, Zhou PH. Outcomes of Endoscopic Submucosal Dissection vs Esophagectomy for T1 Esophageal Squamous Cell Carcinoma in a Real-World Cohort. Clin Gastroenterol Hepatol 2019; 17:73-81.e3. [PMID: 29704682 DOI: 10.1016/j.cgh.2018.04.038] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/12/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy. METHODS We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period. RESULTS Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04). CONCLUSION In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.
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Affiliation(s)
- Yiun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Han Ding
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoen Zhang
- Department of Internal Medicine, Mount Sinai St. Luke's-West Hospital Center, New York, New York
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quanin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Praneet Korrapati
- Department of Gastroenterology, Mount Sinai Beth Israel Hospital, New York, New York
| | - Xue-Juan Jin
- Center of Evidence-Based Medicine, Fudan University, Shanghai, China
| | - Yong-Xing Zhang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
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23
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Histopathology of Barrett’s Esophagus and Early-Stage Esophageal Adenocarcinoma: An Updated Review. GASTROINTESTINAL DISORDERS 2018. [DOI: 10.3390/gidisord1010011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Esophageal adenocarcinoma carries a very poor prognosis. For this reason, it is critical to have cost-effective surveillance and prevention strategies and early and accurate diagnosis, as well as evidence-based treatment guidelines. Barrett’s esophagus is the most important precursor lesion for esophageal adenocarcinoma, which follows a defined metaplasia–dysplasia–carcinoma sequence. Accurate recognition of dysplasia in Barrett’s esophagus is crucial due to its pivotal prognostic value. For early-stage esophageal adenocarcinoma, depth of submucosal invasion is a key prognostic factor. Our systematic review of all published data demonstrates a “rule of doubling” for the frequency of lymph node metastases: tumor invasion into each progressively deeper third of submucosal layer corresponds with a twofold increase in the risk of nodal metastases (9.9% in the superficial third of submucosa (sm1) group, 22.0% in the middle third of submucosa (sm2) group, and 40.7% in deep third of submucosa (sm3) group). Other important risk factors include lymphovascular invasion, tumor differentiation, and the recently reported tumor budding. In this review, we provide a concise update on the histopathological features, ancillary studies, molecular signatures, and surveillance/management guidelines along the natural history from Barrett’s esophagus to early stage invasive adenocarcinoma for practicing pathologists.
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24
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Kidane B, Ali A, Sulman J, Wong R, Knox JJ, Darling GE. Health-related quality of life measure distinguishes between low and high clinical T stages in esophageal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:270. [PMID: 30094256 DOI: 10.21037/atm.2018.06.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Functional Assessment of Cancer Therapy-Esophagus (FACT-E) is a health-related quality of life (HRQOL) instrument validated in patients with esophageal cancer. It is made up of both a general component and an esophageal cancer subscale (ECS). Our objective was to explore the relationship between baseline FACT-E, ECS and clinically determined T-stage in patients with stage II-IV cancer of the gastroesophageal junction or thoracic esophagus. Methods Data from four prospective studies in Canadian academic hospitals were combined. These were consecutive and eligible patients treated between 1996 and 2014 with clinical stage II-IV cancer of the gastroesophageal junction or thoracic esophagus. All patients completed pre-treatment FACT-E. Parametric (ANOVA) and non-parametric (Kruskal-Wallis) analyses were performed. Results Of the 135 patients that were deemed eligible, the T-stage distribution determined clinically was: 10 (7.4%) T1, 33 (24.4%) T2, 79 (58.5%) T3 and 13 (9.6%) T4. Parametric analysis showed no significant association between FACT-E & T-stage, although there was a trend towards significance (P=0.08). Non-parametric analysis showed a significant association between FACT-E and T-stage (P=0.05). Post-hoc tests identified that the most significant differences in FACT-E scores were between T1 and T3 patients. Both parametric (P=0.002) and non-parametric (P=0.003) analyses showed an association between ECS & T-stage. Post-hoc analyses showed significant differences in ECS scores between T1 and higher T-stages (P<0.01). Conclusions Patient-reported HRQOL scores appear to be significantly different in patients with clinical T1 esophageal cancer as compared to those with higher clinical T stages. Since distinguishing T1 from T2/T3 lesions is important in guiding the most appropriate treatment modality and since EUS appears to have difficulties reliably making such T-stage distinctions, FACT-E and ECS scores may be helpful as an adjunct to guide decision-making.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada.,Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Amir Ali
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Joanne Sulman
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Rebecca Wong
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Jennifer J Knox
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
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25
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Seewald S, Ang TL, Pouw RE, Bannwart F, Bergman JJ. Management of Early-Stage Adenocarcinoma of the Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Dig Dis Sci 2018; 63:2146-2154. [PMID: 29934725 DOI: 10.1007/s10620-018-5158-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Barrett's esophagus with high-grade dysplasia and early-stage adenocarcinoma is amenable to curative treatment by endoscopic resection. Histopathological correlation has established that mucosal cancer has minimal risk of nodal metastases and that long-term complete remission can be achieved. Although surgery is the gold-standard treatment once there is submucosal involvement, even T1sm1 (submucosal invasion ≤ 500 μm) cases without additional risk factors for nodal metastases might also be cured with endoscopic resection. Endoscopic resection is foremost an initial diagnostic procedure, and once histopathological assessment confirms that curative criteria are met, it will be considered curative. Endoscopic resection may be achieved by endoscopic mucosal resection, which, although easy to perform with relatively low risk, is limited by an inability to achieve en bloc resection for lesions of size more than 1.5 cm. Conversely, the technique of endoscopic submucosal dissection is more technically demanding with higher risk of complications but is able to achieve en bloc resection for lesions larger than 1.5 cm. Endoscopic submucosal dissection would be particularly important in specific situations such as suspected submucosal invasion and lesion size more than 1.5 cm. In other situations, since endoscopic resection would always be combined with radiofrequency ablation to ablate the remaining Barrett's epithelium, piecemeal endoscopic mucosal resection would suffice since any remnant superficial invisible dysplasia would be ablated.
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Affiliation(s)
- Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Witellikerstrasse 40, 8008, Zurich, Switzerland.
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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26
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Wang K, Chen D, Meng Y, Xu J, Zhang Q. Clinical evaluation of 4 types of microRNA in serum as biomarkers of esophageal squamous cell carcinoma. Oncol Lett 2018; 16:1196-1204. [PMID: 29963194 DOI: 10.3892/ol.2018.8720] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 01/06/2017] [Indexed: 12/26/2022] Open
Abstract
To the best of our knowledge, there is currently no specific biomarker for esophageal cancer used in clinical practice. However, studies consider that microRNAs (miRNAs/miRs) could have useful implications in clinical practice. The present study aimed to investigate the feasibility of using serum microRNAs as biomarkers for esophageal squamous cell carcinoma (ESCC). Using reverse transcription-quantitative polymerase chain reaction, the expression levels of serum miR-21, miR-25, miR-145 and miR-203 were detected in 31 untreated patients with ESCC (EC-UT), 35 inactive period patients with ESCC following treatment (EC-T), 33 patients with esophageal benign disease (benign) and 32 healthy donors (healthy). Furthermore, the ability of these microRNAs to function as biomarkers of ESCC alone and in combination were investigated. The expression levels of serum miR-21, miR-25 and miR-145 in EC-UT were significantly higher than in the other groups (P<0.001). High sensitivity and specificity were shown when miRNAs were used as biomarkers for ESCC, particularly miR-21 and the combination of miR-21 with miR-145. Comparing EC-UT with healthy, benign and EC-T groups, and a combined group (3 groups set as 1 negative control), the sensitivity and specificity of miR-21 were 71.0 and 96.9, 74.2 and 87.9, 77.4 and 82.9, and 74.2 and 88.0%, respectively. The combined sensitivity and specificity of miR-21 and miR-145 were 71.0 and 96.9, 90.9 and 72.7, 97.1 and 82.9, and 80.6 and 80.0%, respectively. In conclusion, 3 types of miRNA (miR-21, miR-25 and miR-145) in serum could serve as potential biomarkers for ESCC. Furthermore, the expression level of miR-145 in serum was upregulated, compared with the downregulation reported in previous studies in ESCC tissues and cells.
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Affiliation(s)
- Kai Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Clinical Laboratory, Peking University Cancer Hospital and Institute, Beijing 100142, P.R. China
| | - Dongmei Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Clinical Laboratory, Peking University Cancer Hospital and Institute, Beijing 100142, P.R. China
| | - Yue Meng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Clinical Laboratory, Peking University Cancer Hospital and Institute, Beijing 100142, P.R. China
| | - Jianjun Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Clinical Laboratory, Peking University Cancer Hospital and Institute, Beijing 100142, P.R. China
| | - Qingyun Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Clinical Laboratory, Peking University Cancer Hospital and Institute, Beijing 100142, P.R. China
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27
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Waterhouse DJ, Fitzpatrick CRM, di Pietro M, Bohndiek SE. Emerging optical methods for endoscopic surveillance of Barrett's oesophagus. Lancet Gastroenterol Hepatol 2018; 3:349-362. [PMID: 29644977 DOI: 10.1016/s2468-1253(18)30030-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/21/2017] [Accepted: 01/22/2018] [Indexed: 12/11/2022]
Abstract
Barrett's oesophagus is an acquired metaplastic condition that predisposes patients to the development of oesophageal adenocarcinoma, prompting the use of surveillance regimes to detect early malignancy for endoscopic therapy with curative intent. The currently accepted surveillance regime uses white light endoscopy together with random biopsies, but has poor sensitivity and discards information from numerous light-tissue interactions that could be exploited to probe structural, functional, and molecular changes in the tissue. Advanced optical methods are now emerging that are highly sensitive to these changes and hold potential to improve surveillance of Barrett's oesophagus if they can be applied endoscopically. The next decade will see some of these exciting new methods applied to surveillance of Barrett's oesophagus in new device architectures for the first time, potentially leading to a long-awaited improvement in the standard of care.
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Affiliation(s)
- Dale J Waterhouse
- Department of Physics, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Catherine R M Fitzpatrick
- Department of Physics, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK; Department of Electrical Engineering, University of Cambridge, Cambridge, UK
| | | | - Sarah E Bohndiek
- Department of Physics, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK.
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28
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Nelson DB, Dhupar R, Katkhuda R, Correa A, Goltsov A, Maru D, Sepesi B, Antonoff MB, Mehran RJ, Rice DC, Vaporciyan AA, Davila M, Davila R, Betancourt S, Ajani J, Hofstetter WL. Outcomes after endoscopic mucosal resection or esophagectomy for submucosal esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2018; 156:406-413.e3. [PMID: 29605441 DOI: 10.1016/j.jtcvs.2018.02.093] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 01/02/2018] [Accepted: 02/01/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic mucosal resection (EMR) is a diagnostic and potentially therapeutic option for patients with submucosal esophageal adenocarcinoma. However, there are significant concerns regarding the risk of lymph node metastasis. Our purpose was to construct a comparative effectiveness analysis comparing recurrence patterns after therapeutic EMR or esophagectomy. METHODS Patients who underwent therapeutic EMR or esophagectomy from 2007 to 2015 with pathologically staged submucosal adenocarcinoma were identified from a departmental database. Cancer-related outcomes were compared among an unmatched as well as a propensity matched cohort. Risk stratification was also used to compare results among those with a low, medium, or high risk of nodal metastasis. RESULTS Seventy-two patients met criteria for analysis, among whom 23 underwent therapeutic EMR with esophageal preservation and 49 underwent esophagectomy. Median follow-up was 43 months. Patients who underwent esophagectomy had larger, deeper tumors. Esophageal preservation was associated with an increased risk of local recurrence (P = .01), but not distant recurrence (P = .44). After propensity matching, there continued to be no difference in distant recurrence rate (P = .66). In a risk-stratified analysis, low-risk patients showed no recurrences or cancer-related deaths, however, high-risk patients showed a trend toward increased distant recurrence after therapeutic EMR. CONCLUSIONS Esophageal preservation after therapeutic EMR was associated with an increased risk of local recurrence. Among low-risk patients, either strategy resulted in excellent cancer control. However, among high-risk patients, esophageal preservation showed a trend toward increased distant failure. These findings should prompt further investigation to determine optimal treatment for patients with submucosal esophageal adenocarcinoma.
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Affiliation(s)
- David B Nelson
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Rajeev Dhupar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Riham Katkhuda
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Arlene Correa
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Alexei Goltsov
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Dipen Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Marta Davila
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Raquel Davila
- Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Sonia Betancourt
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jaffer Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex.
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29
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McLaren PJ, Dolan JP. Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer. World J Surg 2018; 41:1712-1718. [PMID: 28258451 DOI: 10.1007/s00268-017-3958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option. METHODS The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy. RESULTS The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy. CONCLUSIONS When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.
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Affiliation(s)
- Patrick J McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA.
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30
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Esophagectomy versus endoscopic resection for patients with early-stage esophageal adenocarcinoma: A National Cancer Database propensity-matched study. J Thorac Cardiovasc Surg 2018; 155:2211-2218.e1. [PMID: 29455958 DOI: 10.1016/j.jtcvs.2017.11.111] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 10/07/2017] [Accepted: 11/22/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Endoscopic resection has been rapidly adopted in the treatment of early-stage esophageal tumors. We compared the outcomes after esophagectomy or endoscopic resection for stage T1a adenocarcinoma. METHODS We queried the National Cancer Database for patients with T1a esophageal adenocarcinoma who underwent esophagectomy or endoscopic resection and generated a balanced cohort with 735 matched pairs using propensity-score matching. We then performed a multivariable Cox regression analysis on the matched and unmatched cohorts. RESULTS We identified 2173 patients; 1317 (60.6%) underwent esophagectomy, and 856 (39.4%) underwent endoscopic resection. In the unmatched cohort, patients who underwent esophagectomy were younger, more often not treated in academic settings, and more likely to have comorbidities (30.4% vs 22.5%, P = .002). They had longer hospital stays and more readmissions than patients who underwent endoscopic resection. Factors positively affecting overall survival were younger age, resection at an academic medical center, and lower Charlson-Deyo comorbidity score. In the matched cohort, patients who underwent esophagectomy had longer hospital stays and were more likely to be readmitted within 30 days (7.0% vs 0.6%, P < .001). When a time period-specific partition was applied, endoscopic resection had a lower death hazard 0 to 90 days after resection (hazard ratio, 0.15; P = .003), but this was reversed for survival greater than 90 days (hazard ratio, 1.34; P = .02). CONCLUSIONS In patients with early-stage esophageal adenocarcinoma, survival appears equivalent after endoscopic resection or esophagectomy, but endoscopic resection is associated with shorter hospital stays, fewer readmissions, and less 90-day mortality. In patients surviving more than 90 days, esophagectomy may provide better overall survival.
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31
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Upchurch E, Griffiths S, Lloyd GR, Isabelle M, Kendall C, Barr H. Developments in optical imaging for gastrointestinal surgery. Future Oncol 2017; 13:2363-2382. [PMID: 29121775 DOI: 10.2217/fon-2017-0181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
To improve outcomes for patients with cancer, in terms of both survival and a reduction in the morbidity and mortality that results from surgical resection and treatment, there are two main areas that require improvement. Accurate early diagnosis of the cancer, at a stage where curative and, ideally, minimally invasive treatment is achievable, is desired as well as identification of tumor margins, lymphatic and distant disease, enabling complete, but not unnecessarily extensive, resection. Optical imaging is making progress in achieving these aims. This review discusses the principles of optical imaging, focusing on fluorescence and spectroscopy, and the current research that is underway in GI tract carcinomas.
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Affiliation(s)
- Emma Upchurch
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN.,Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Shelly Griffiths
- Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Gavin-Rhys Lloyd
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Martin Isabelle
- Renishaw plc, New Mills, Wotton-under-Edge, Gloucestershire, UK, GL12 8JR
| | - Catherine Kendall
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
| | - Hugh Barr
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN.,Department of Upper GI Surgery, Gloucestershire Royal Hospital, Great Western Road, Gloucester, UK, GL1 3NN
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32
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Antonoff MB. Scoring system to predict nodal metastases in patients with early-stage esophageal cancer: An outstanding tool to complement multidisciplinary, team-based care. J Thorac Cardiovasc Surg 2017; 154:1794-1795. [PMID: 29042050 DOI: 10.1016/j.jtcvs.2017.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex.
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33
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Weksler B, Kennedy KF, Sullivan JL. Using the National Cancer Database to create a scoring system that identifies patients with early-stage esophageal cancer at risk for nodal metastases. J Thorac Cardiovasc Surg 2017; 154:1787-1793. [PMID: 28867381 DOI: 10.1016/j.jtcvs.2017.07.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/08/2017] [Accepted: 07/16/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Endoscopic resection is gaining popularity as a treatment for early-stage esophageal adenocarcinoma, particularly for T1a tumors. The goal of this study was to create a scoring system to reflect the risk of nodal metastases in early-stage esophageal adenocarcinoma to be used after endoscopic resection to better individualize treatment. METHODS The National Cancer Database was queried for patients with T1a or T1b esophageal adenocarcinoma who underwent esophagectomy. We identified variables affecting nodal metastases using multivariable logistic regression, which we then used to create a scoring system. We stratified the model for T1a or T1b tumors, tested model discrimination, and validated the models by refitting in 1000 bootstrap samples. C-statistics greater than 0.7 were considered relevant. RESULTS We identified 1283 patients with T1a or T1b tumors; 146 had nodal metastases (11.4%). Tumor category (pT1a vs pT1b), grade, and size and the presence of angiolymphatic invasion significantly affected the risk of nodal metastases. We assigned points to each variable and added them to get a risk score. In patients with T1a tumors, less than 3% of patients with a risk score of 3 or less had nodal metastases, whereas 16.1% of patients with a risk score of 5 or greater had nodal metastases. In patients with T1b tumors, less than 5% of patients with a risk score of 2 or less had nodal metastases, whereas 41% of patients with a score of 6 or greater had nodal metastases (c-statistic = 0.805). CONCLUSIONS The proposed scoring system seems to be useful in discriminating risk of nodal metastases in patients with T1a or T1b esophageal adenocarcinoma and may be useful in directing patients who received endoscopic resection to esophagectomy or careful follow-up.
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Affiliation(s)
- Benny Weksler
- Division of Thoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tenn.
| | - Kevin F Kennedy
- Department of Biostatistics, St Lukes Health System, Mid America Heart Institute, Kansas City, Mo
| | - Jennifer L Sullivan
- Division of Thoracic Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tenn
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Ishihara R, Oyama T, Abe S, Takahashi H, Ono H, Fujisaki J, Kaise M, Goda K, Kawada K, Koike T, Takeuchi M, Matsuda R, Hirasawa D, Yamada M, Kodaira J, Tanaka M, Omae M, Matsui A, Kanesaka T, Takahashi A, Hirooka S, Saito M, Tsuji Y, Maeda Y, Yamashita H, Oda I, Tomita Y, Matsunaga T, Terai S, Ozawa S, Kawano T, Seto Y. Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population. J Gastroenterol 2017; 52:800-808. [PMID: 27757547 DOI: 10.1007/s00535-016-1275-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/07/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors. METHODS We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection. RESULTS Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions). CONCLUSIONS Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection.
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Affiliation(s)
- Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka, 537-8511, Japan.
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Takahashi
- Department of Gastroenterology, Keiyukai Daini Hospital, Sapporo, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Kenichi Goda
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenro Kawada
- Department of Esophageal and General Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Rie Matsuda
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Dai Hirasawa
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Junichi Kodaira
- Department of Gastroenterology, Keiyukai Daini Hospital, Sapporo, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masami Omae
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akira Matsui
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 3-3 Nakamichi 1-chome, Higashinari-ku, Osaka, 537-8511, Japan
| | - Akiko Takahashi
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Shinichi Hirooka
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuki Maeda
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Hiroharu Yamashita
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Ichiro Oda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiko Tomita
- Department of Pathology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Takashi Matsunaga
- Department of Medical Informatics, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Tatsuyuki Kawano
- Department of Esophageal and General Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Di Leo A, Zanoni A. Siewert III adenocarcinoma: treatment update. Updates Surg 2017; 69:319-325. [PMID: 28303519 DOI: 10.1007/s13304-017-0429-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/08/2017] [Indexed: 12/21/2022]
Abstract
Siewert III cancer, although representing around 40% of EGJ cancers and being the EGJ cancer with worst prognosis, does not have a homogenous treatment, has few dedicated studies, and is often not considered in study protocols. Although staged as an esophageal cancer by the TNM 7th ed., it is considered a gastric cancer by new TNM 8th ed. Our aim was to consolidate the current literature on the indications and treatment options for Siewert III adenocarcinoma. A review of the literature was performed to better delineate treatment indications (according to stage, surgical margins, type of lymphatic spread and lymphadenectomy) and treatment strategy. The treatment approach is strictly dependent on cancer site and nodal diffusion. T1m cancers have insignificant risk of nodal metastases and can be safely treated with endoscopic resections. The risk of nodal metastases increases markedly starting from T1sm cancers and requires surgery with lymphadenectomy. The site of this type of cancer and the nodal diffusion require a total gastrectomy and distal esophagectomy, with 5 cm of clear proximal and distal margins and a D2 abdominal and inferior mediastinal lymphadenectomy. Multimodal treatments are indicated in all locally advanced and node positive cancers. Siewert III cancers are gastric cancers with some peculiarities and require dedicated studies and deserve more consideration in the current literature, especially because their treatment is particularly challenging.
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Affiliation(s)
- Alberto Di Leo
- Unit of General Surgery, Rovereto Hospital, APSS of Trento, Corso Verona 4, 38068, Rovereto, TN, Italy.
| | - Andrea Zanoni
- Unit of General Surgery, Rovereto Hospital, APSS of Trento, Corso Verona 4, 38068, Rovereto, TN, Italy
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Old OJ, Isabelle M, Barr H. Staging Early Esophageal Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 908:161-81. [PMID: 27573772 DOI: 10.1007/978-3-319-41388-4_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Staging esophageal cancer provides a standardized measure of the extent of disease that can be used to inform decisions about therapy and guide prognosis. For esophageal cancer, the treatment pathways vary greatly depending on stage of disease, and accurate staging is therefore crucial in ensuring the optimal therapy for each patient. For early esophageal cancer (T1 lesions), endoscopic resection can be curative and simultaneously gives accurate staging of depth of invasion. For tumors invading the submucosa or more advanced disease, comprehensive investigation is required to accurately stage the tumor and assess suitability for curative resection. A combined imaging approach of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) offers complementary diagnostic information and gives the greatest chance of accurate staging. Staging laparoscopy can identify peritoneal disease and small superficial liver lesions that could be missed on CT or PET, and alters management in up to 20 % of patients. Optical diagnostic techniques offer the prospect of further extending the possibilities of endoscopic staging in real time. Optical coherence tomography can image superficial lesions and could provide information on depth of invasion for these lesions. Real-time lymph node analysis using optical diagnostics such as Raman spectroscopy could be used to support immediate endoscopic therapy without waiting for results of cytology or further investigations.
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Affiliation(s)
- O J Old
- Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucester, UK. .,Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK.
| | - M Isabelle
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK
| | - H Barr
- Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucester, UK
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Osumi H, Fujisaki J, Omae M, Shimizu T, Yoshio T, Ishiyama A, Hirasawa T, Tsuchida T, Yamamoto Y, Kawachi H, Yamamoto N, Igarashi M. Meta-analysis of lymph node metastasis in Siewert type I and II T1 adenocarcinomas. World J Meta-Anal 2016; 4:118-123. [DOI: 10.13105/wjma.v4.i6.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 09/13/2016] [Accepted: 10/24/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the incidence of lymph node metastasis (LNM) and its risk factors in patients with Siewert type I and type II pT1 adenocarcinomas.
METHODS We enrolled 85 patients [69 men, 16 women; median age (range), 67 (38-84) years] who had undergone esophagectomy or proximal gastrectomy for Siewert type I and type II pT1 adenocarcinomas. Predictive risk factors of LNM included age, sex, location of the tumor center, confirmed Barrett’s esophageal adenocarcinoma, tumor size, macroscopic tumor type, pathology, invasion depth, presence of ulceration, and lymphovascular invasion. Multivariate logistic regression analysis was used to identify factors predicting LNM. We also evaluated the frequencies of LNM for Siewert type I and type II pT1 adenocarcinomas in meta-data analysis.
RESULTS LNMs were found in 11 out of 85 patients (12.9%, 95%CI: 5.8-20.0). Only 1 of the 15 patients (6.6%, 95%CI: 0.0-19.2) who had a final diagnosis of pT1a adenocarcinoma had a positive LNM, whereas 10 of the 70 patients (14.2%, 95%CI: 6.0-22.4) with a final diagnosis of pT1b adenocarcinoma had positive LNM. Furthermore, only one of the 30 patients (3.3%, 95%CI: 0.0-9.7) with a tumor invasion depth within 500 μm from muscularis mucosae had positive LNM. Poor differentiation and lymphovascular invasion were independently associated with a risk of LNM. In meta-data analysis, 12 of the 355 patients (3.3%, 95%CI: 1.5-5.2) who had a final diagnosis of pT1a adenocarcinoma had a positive LNM, whereas 91 of the 438 patients (20.7%, 95%CI: 16.9-24.5) with a final diagnosis of pT1b adenocarcinoma had positive LNM.
CONCLUSION We consider endoscopic submucosal dissection (ESD) is suitable for patients with Siewert type I and type II T1a adenocarcinomas. For patients with T1b adenocarcinoma, especially invasion depth is within 500 μm from muscularis mucosae with no other risk factor for LNM, diagnostic ESD could be a treatment option according to the overall status of patients and the presence of comorbidities.
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Schölvinck D, Künzli H, Meijer S, Seldenrijk K, van Berge Henegouwen M, Bergman J, Weusten B. Management of patients with T1b esophageal adenocarcinoma: a retrospective cohort study on patient management and risk of metastatic disease. Surg Endosc 2016; 30:4102-13. [PMID: 27357927 DOI: 10.1007/s00464-016-5071-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/21/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Esophagectomy for submucosal (T1b) esophageal adenocarcinoma (EAC) is performed in order to optimize patient outcomes given the risk of concurrent lymph node metastases (LNM). However, not seldom, comorbidity precludes these patients from surgery. Therefore, the aim of our study was to assess the course of follow-up after treatment in submucosal EAC patients undergoing surgery versus conservative therapy and to evaluate the incidence of metastatic disease. METHODS Between 2001 and 2012, all patients undergoing diagnostic endoscopic resection for EAC in two centers were reviewed. Only patients with histopathologically proven submucosal tumor invasion were included. Submucosal EACs were divided into tumors that were removed radically (R0) and irradically (R1). Subsequently, in the R0 group, EACs were classified as either low risk (LR; submucosal invasion <500 nm, G1-G2, no LVI) or high risk (HR; deep submucosal invasion >500 nm, G3-G4 and/or LVI). Metastatic disease was defined as LNM in surgical resection specimen and/or evidence of malignant disease during follow-up (FU). RESULTS Sixty-nine patients with a submucosal EAC were included [23 R1-resections and 46 R0-resection (14 R0-LR and 32 R0-HR)]. Twenty-six patients underwent surgical treatment (1 R0-LR, 12 R0-HR and 13 R1). None of the 14 R0-LR patients developed metastatic disease after a median FU of 60 months. In the R0-HR group and R1 group, metastatic disease was diagnosed in 16 and 30 % of patients, respectively. Surgical patients tended to have a better overall survival than non-surgical patients (p = 0.09). Tumor-related deaths, however, were 12 % in both groups. CONCLUSIONS In LR submucosal EAC, the risk of metastatic disease appears to be very low. In deep submucosal EAC (either R0- or R1-resection), the rate of metastatic disease is lower than reported in earlier surgical series. Given the reasonable disease-free survival and high background mortality, conservative management of these patients seems to be a valid alternative for surgery in selected cases.
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Affiliation(s)
- Dirk Schölvinck
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hannah Künzli
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Pathology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Kees Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands
| | | | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Boniface MM, Wani SB, Schefter TE, Koo PJ, Meguid C, Leong S, Kaplan JB, Wingrove LJ, McCarter MD. Multidisciplinary management for esophageal and gastric cancer. Cancer Manag Res 2016; 8:39-44. [PMID: 27217796 PMCID: PMC4853141 DOI: 10.2147/cmar.s101169] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The management of esophageal and gastric cancer is complex and involves multiple specialists in an effort to optimize patient outcomes. Utilizing a multidisciplinary team approach starting from the initial staging evaluation ensures that all members are in agreement with the plan of care. Treatment selection for esophageal and gastric cancer often involves a combination of chemotherapy, radiation, surgery, and palliative interventions (endoscopic and surgical), and direct communication between specialists in these fields is needed to ensure appropriate clinical decision making. At the University of Colorado, the Esophageal and Gastric Multidisciplinary Clinic was created to bring together all experts involved in treating these diseases at a weekly conference in order to provide patients with coordinated, individualized, and patient-centered care. This review details the essential elements and benefits of building a multidisciplinary program focused on treating esophageal and gastric cancer patients.
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Affiliation(s)
- Megan M Boniface
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, Department of Therapeutic and Interventional Endoscopy, University of Colorado Denver, Aurora, CO, USA
| | - Tracey E Schefter
- Department of Radiation Oncology, University of Colorado Denver, Aurora, CO, USA
| | - Phillip J Koo
- Division of Radiology-Nuclear Medicine, Department of Radiology, University of Colorado Denver, Aurora, CO, USA
| | - Cheryl Meguid
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Stephen Leong
- Division of Medical Oncology, University of Colorado Denver, Aurora, CO, USA
| | - Jeffrey B Kaplan
- Department of Pathology, University of Colorado Denver, Aurora, CO, USA
| | - Lisa J Wingrove
- Department of Food and Nutrition Services, University of Colorado Hospital Cancer Center, Aurora, CO, USA
| | - Martin D McCarter
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
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Emerging Concepts for the Endoscopic Management of Superficial Esophageal Adenocarcinoma. J Gastrointest Surg 2016; 20:851-60. [PMID: 26691147 DOI: 10.1007/s11605-015-3056-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 12/07/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Endoscopic therapy has revolutionized the treatment of Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal adenocarcinoma by allowing preservation of the esophagus in many patients who would previously have had an esophagectomy. This paradigm shift initially occurred at high-volume centers in North America and Europe but now is becoming mainstream therapy. There is a lack of uniform guidelines and algorithms for the management of these patients. Our aim was to review important concepts and pitfalls in the endoscopic management of superficial esophageal adenocarcinoma. METHODS A small group colloquium consisting of gastroenterologists, surgeons, and pathologists reviewed published data and discussed personal and institutional experiences with endotherapy for HGD and superficial esophageal adenocarcinoma. RESULTS The group reviewed data and provided recommendations and management algorithms for seven areas pertaining to endoscopic therapy for Barrett's HGD and superficial adenocarcinoma: (1) patient selection and evaluation; (2) imaging and biopsy techniques; (3) devices; (4) indications for resection versus ablation; (5) ER specimen handling, processing, and pathologic evaluation; (6) patient care and follow-up after endoscopic therapy; and (7) complications of endoscopic therapy and treatment options. CONCLUSIONS Endoscopic therapy is preferred over esophagectomy for most patients with HGD or intramucosal adenocarcinoma, and may be applicable to select patients with submucosal tumors. Clear guidelines and management algorithms will aid physicians and centers embarking on endoscopic therapy and enable a standardized approach to the management of these patients that is applicable internationally.
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Davison JM, Landau MS, Luketich JD, McGrath KM, Foxwell TJ, Landsittel DP, Gibson MK, Nason KS. A Model Based on Pathologic Features of Superficial Esophageal Adenocarcinoma Complements Clinical Node Staging in Determining Risk of Metastasis to Lymph Nodes. Clin Gastroenterol Hepatol 2016; 14:369-377.e3. [PMID: 26515637 PMCID: PMC4776749 DOI: 10.1016/j.cgh.2015.10.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is important to identify superficial (T1) gastroesophageal adenocarcinomas (EAC) that are most or least likely to metastasize to lymph nodes, to select appropriate therapy. We aimed to develop a risk stratification model for metastasis of superficial EAC to lymph nodes using pathologic features of the primary tumor. METHODS We collected pathology data from 210 patients with T1 EAC who underwent esophagectomy from 1996 through 2012 on factors associated with metastasis to lymph nodes (tumor size, grade, angiolymphatic invasion, and submucosal invasion). Using these variables, we developed a multivariable logistic model to generate 4 categories for estimated risk of metastasis (<5% risk, 5%-10% risk, 15%-20% risk, or >20% risk). The model was validated in a separate cohort of 39 patients who underwent endoscopic resection of superficial EAC and subsequent esophagectomy, with node stage analysis. RESULTS We developed a model based on 4 pathologic factors that determined risk of metastasis to range from 2.9% to 60% for patients in the first cohort. In the endoscopic resection validation cohort, higher risk scores were associated with increased detection of lymph node metastases at esophagectomy (P = .021). Among patients in the first cohort who did not have lymph node metastases detected before surgery (cN0), those with high risk scores (>20% risk) had 11-fold greater odds for having lymph node metastases at esophagectomy compared with patients with low risk scores (95% confidence interval, 2.3-52 fold). Increasing risk scores were associated with reduced patient survival time (P < .001) and shorter time to tumor recurrence (P < .001). Patients without lymph node metastases (pT1N0) but high risk scores had reduced times of survival (P < .001) and time to tumor recurrence (P = .001) after esophagectomy than patients with pT1N0 tumors and lower risk scores. CONCLUSIONS Pathologic features of primary superficial EACs can be used, along with the conventional node staging system, to identify patients at low risk for metastasis, who can undergo endoscopic resection, or at high risk, who may benefit from induction or adjuvant therapy.
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Affiliation(s)
- Jon M. Davison
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael S. Landau
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - James D. Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kevin M. McGrath
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Tyler J. Foxwell
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas P. Landsittel
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Michael K. Gibson
- Department of Medicine; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Katie S. Nason
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Werbrouck E, De Hertogh G, Sagaert X, Coremans G, Willekens H, Demedts I, Bisschops R. Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett's neoplasia. United European Gastroenterol J 2016; 4:663-668. [PMID: 27733908 DOI: 10.1177/2050640615626320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/13/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett's neoplasia. Adequate staging is important to assure a good oncological outcome. OBJECTIVE The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett's oesophagus (BE) and the cardia. METHODS Between November 2005-May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen. RESULTS The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%). CONCLUSION The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett's dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barrett's dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.
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Affiliation(s)
- E Werbrouck
- Department of General Medical Oncology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - G De Hertogh
- Department of Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - X Sagaert
- Department of Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - G Coremans
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - H Willekens
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - I Demedts
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - R Bisschops
- Department of Gastroenterology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
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Boys JA, Worrell SG, Chandrasoma P, Vallone JG, Maru DM, Zhang L, Blackmon SH, Dickinson KJ, Dunst CM, Hofstetter WL, Lada MJ, Louie BE, Molena D, Watson TJ, DeMeester SR. Can the Risk of Lymph Node Metastases Be Gauged in Endoscopically Resected Submucosal Esophageal Adenocarcinomas? A Multi-Center Study. J Gastrointest Surg 2016; 20:6-12; discussion 12. [PMID: 26408330 DOI: 10.1007/s11605-015-2950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic resection (ER) allows for local therapy of superficial esophageal cancers. Factors reported to be associated with an increased risk of lymph node metastases in patients with adenocarcinoma are poor differentiation, lymphovascular invasion (LVI), and submucosal invasion >500 μ. The aim of this study was to determine whether depth of invasion and tumor characteristics in an ER specimen can be used to gauge the risk of lymph node metastases in patients with superficial esophageal adenocarcinoma. Patients from seven US centers that had ER of an adenocarcinoma followed by an esophagectomy were identified. The ER pathology slides were rereviewed by three experienced GI pathologists for depth of invasion, presence of LVI, and tumor differentiation. The findings from the ER specimen were correlated with the presence and number of lymph node metastases in the final esophagectomy specimen. There were 19 T1a and 23 T1b tumors. A median of 24 nodes were resected per patient. None of the T1a tumors had involved lymph nodes despite the presence of LVI in 5% and poor differentiation in 21% of patients. In contrast, 26% of T1b tumors had involved nodes. None of the four patients with submucosal invasion ≤500 μ, no LVI, and no poor differentiation had involved nodes. However, with an increasing number of risk factors, the likelihood of involved lymph nodes increased, reaching 50% when all three factors were present. Endoscopic therapy appears appropriate for intramucosal tumors and may be an option for low-risk T1b tumors. Esophagectomy is preferred for patients with submucosal invasion and one or more risk factors.
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Affiliation(s)
- Joshua A Boys
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Stephanie G Worrell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
| | - Parakrama Chandrasoma
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John G Vallone
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dipen M Maru
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Wayne L Hofstetter
- Department of Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Lada
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Brian E Louie
- Department of Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Daniela Molena
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas J Watson
- Department of Surgery, University of Rochester, New York, NY, USA
| | - Steven R DeMeester
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA.
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Fotis D, Doukas M, Wijnhoven BP, Didden P, Biermann K, Bruno MJ, Koch AD. Submucosal invasion and risk of lymph node invasion in early Barrett's cancer: potential impact of different classification systems on patient management. United European Gastroenterol J 2015; 3:505-13. [PMID: 26668743 DOI: 10.1177/2050640615581965] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Due to the high mortality and morbidity rates of esophagectomy, endoscopic mucosal resection (EMR) is increasingly used for the curative treatment of early low risk Barrett's adenocarcinoma. OBJECTIVE This retrospective cohort study aimed to assess the prevalence of lymph node metastases (LNM) in submucosal (T1b) esophageal adenocarcinomas (EAC) in relation to the absolute depth of submucosal tumor invasion and demonstrate the efficacy of EMR for low risk (well and moderately differentiated without lymphovascular invasion) EAC with sm1 invasion (submucosal invasion ≤500 µm) according to the Paris classification. METHODS The pathology reports of patients undergoing endoscopic resection and surgery from January 1994 until December 2013 at one center were reviewed and 54 patients with submucosal invasion were included. LNM were evaluated in surgical specimens and by follow up examinations in case of EMR. RESULTS No LNM were observed in 10 patients with sm1 adenocarcinomas that underwent endoscopic resection. Three of them underwent supplementary endoscopic eradication therapy with a median follow up of 27 months for patients with sm1 tumors. In the surgical series two patients (29%) with sm1 invasion according to the pragmatic classification (subdivision of the submucosa into three equal thirds), staged as sm2-3 in the Paris classification, had LNM. The rate of LNM for surgical patients with low risk sm1 tumors was 10% according to the pragmatic classification and 0% according to Paris classification. CONCLUSION Different classifications of the tumor invasion depth lead to different LNM risks and treatment strategies for sm1 adenocarcinomas. Patients with low risk sm1 adenocarcinomas appear to be suitable candidates for EMR.
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Affiliation(s)
- Dimitrios Fotis
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Bas Pl Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
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Matsuda T, Takeuchi H, Tsuwano S, Nakahara T, Mukai M, Kitagawa Y. Sentinel node mapping in adenocarcinoma of the esophagogastric junction. World J Surg 2015; 38:2337-44. [PMID: 24752362 DOI: 10.1007/s00268-014-2573-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing, but the surgical strategy for AEG remains controversial. We hypothesized that sentinel node (SN) mapping for AEG could be validated to avoid unnecessary lymphadenectomy and permit minimally invasive surgery. We examined the feasibility of SN mapping for AEG. METHODS We enrolled 15 patients with preoperatively diagnosed cT1 N0 M0 primary AEG (Siewert type I, N = 3; Siewert type II, N = 12) lesions measuring <4 cm in diameter. The dual tracer method employing radioactive colloid and blue dye was used to detect SNs. The distribution of SNs was compared with that of metastatic lymph nodes in 52 patients who were surgically treated without SN mapping. RESULTS SNs were successfully identified in all the patients. Two patients with lymph node metastasis had positive SNs identified via an intraoperative pathological examination, and the diagnostic sensitivity and accuracy based on the SN status were both 100 %. For Siewert type II AEG, the SNs were not detected in the lower mediastinum by intraoperative gamma probing. Thus, all surgical procedures were performed via a transhiatal approach. No patient without SN metastasis experienced cancer recurrence during a 38-month median follow-up. The distribution of SNs was similar to that of lymph node metastasis in the patients who were surgically treated without SN mapping. CONCLUSIONS We achieved 100 % SN detection. Our results suggested that SN mapping is feasible for AEG and highly sensitive and accurate in diagnosing lymph node metastasis. SN mapping may clarify the necessity of mediastinal lymph node dissection and individualize minimally invasive surgery.
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Affiliation(s)
- Tatsuo Matsuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Li ZG, Zhu H, Shi H, Xie H, Goldblum JR, Thota PN, Liu X. Lymphovascular invasion and nodal metastasis in intramucosal adenocarcinoma of the esophagus and esophagogastric junction. J Dig Dis 2015; 16:197-204. [PMID: 25620066 DOI: 10.1111/1751-2980.12230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the tumor parameters predictive of lymphovascular invasion (LVI) and nodal metastases in intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction. METHODS In all, 171 cases of IMAC from esophagectomy database (1986-2009) were reviewed. LVI was evaluated on HE and by immunohistochemistry stain for D2-40 (in selected cases). Univariate analysis was performed to identify predictors for LVI (in this cohort) and nodal metastasis (for pooled data from literature review). RESULTS Altogether 150 IMAC were included in the study after histology review; 7 (4.7%) showed LVI and one (0.7%) had nodal metastasis. LVI-positive IMAC were thicker (tumor thickness 3.0 ± 2.8 mm vs 1.3 ± 1.2 mm, P = 0.01), and more likely to invade the outer muscularis mucosae (M3) (P = 0.004), be poorly differentiated (P < 0.001), and to show a nodular or plaque-like lesion (P = 0.04) compared with LVI-negative IMAC. Patients' age, gender, the frequency of tumor multifocality, ulceration and tumor size were not significantly different between these two groups. The pooled rates of LVI and nodal metastases in IMAC from five published studies and this cohort were 6.0% (range 2.9-16.7%) and 3.4% (range 0-10.0%), respectively. Pooled analysis of studies with histology review showed that LVI in IMAC was associated with a nodal metastases rate of 27.3%. CONCLUSION For IMAC of the esophagus and esophagogastric junction, LVI is associated with tumor thickness, M3 invasion, poor differentiation and the presence of nodular or plaque-like lesion; by pooled analysis, it is associated with a risk of nodal metastasis of 27.3%.
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Affiliation(s)
- Zhi Gang Li
- Department of Surgery, Second Military Medical University, Shanghai, China
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Old OJ, Almond LM, Barr H. Barrett's oesophagus: how should we manage it? Frontline Gastroenterol 2015; 6:108-116. [PMID: 28839797 PMCID: PMC5369571 DOI: 10.1136/flgastro-2014-100552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/09/2015] [Indexed: 02/04/2023] Open
Abstract
Endoscopic surveillance remains the core management of non-dysplastic Barrett's oesophagus, although questions regarding its efficacy in reducing mortality from oesophageal adenocarcinoma have yet to be definitively answered, and randomised trial data are awaited. One of the main goals of current research is to achieve risk stratification, identifying those at high risk of progression. The recent British Society of Gastroenterology (BSG) guidelines on surveillance have taken a step in this direction with interval stratification on clinicopathological grounds. The majority of Barrett's oesophagus remains undiagnosed, and this has led to investigation of methods of screening for Barrett's oesophagus, ideally non-endoscopic methods capable of reliably identifying dysplasia. Chemoprevention to prevent progression is currently under investigation, and may become a key component of future treatment. The availability of effective endotherapy means that accurate identification of dysplasia is more important than ever. There is now evidence to support intervention with radiofrequency ablation (RFA) for low-grade dysplasia (LGD), but recent data have emphasised the need for consensus pathology for LGD. Ablative treatment has become well established for high-grade dysplasia, and should be employed for flat lesions where there is no visible abnormality. Of the ablative modalities, RFA has the strongest evidence base. Endoscopic resection should be performed for all visible lesions, and is now the treatment of choice for T1a tumours. Targeting those with high-risk disease will, hopefully, lead to efficacious and cost-effective surveillance, and the trend towards earlier intervention to halt progression gives cause for optimism that this will ultimately result in fewer deaths from oesophageal adenocarcinoma.
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Affiliation(s)
- O J Old
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Trust, Gloucester, UK,Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Trust, Gloucester, UK
| | - L M Almond
- Upper GI Surgery Department, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - H Barr
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Trust, Gloucester, UK,Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Trust, Gloucester, UK
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Perry C, Soomro I, Kaye P, Hardy E, Parsons SL, Ragunath K, Lobo DN, Martin SG, Madhusudan S. Analysis of lymphatic and blood vessel invasion biomarkers in T1 esophagogastric adenocarcinomas for improved patient prognostication. Dis Esophagus 2015; 28:262-8. [PMID: 24612464 DOI: 10.1111/dote.12190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Lymphovascular invasion (LVI) in T1 esophagogastric adenocarcinoma may predict risk of recurrence despite definitive treatment with surgery or endoscopic resection. Podoplanin and CD34 are emerging biomarkers of lymphatic and blood vessel invasion, respectively, and could be adopted to refine LVI assessment. A consecutive series of 65 patients with T1 adenocarcinomas diagnosed at Nottingham University Hospitals were investigated. T1 tumors from 43/65 patients who received primary surgery only were suitable for LVI evaluation by hematoxylin and eosin (H&E) staining as well as by CD34 and Podoplanin immunohistochemistry. LVI was correlated to clinicopathological features and recurrence free survival. H&E staining detected LVI in 11.6% (5/43) of T1 tumors. CD34 and Podoplanin immunohistochemistry significantly improved LVI detection to 25.6% (11/43). Compared with LVI by H&E, immunohistochemical evaluation of blood vessel invasion (CD34) or lymphatic vessel invasion (Podoplanin) was significantly associated with higher grade (P = 0.005), submucosal invasion (T1b) (P = 0.018), lymph node positivity (N1) (P = 0.029) and poor recurrence free survival (P = 0.0003). Our study provides evidence that CD34 and Podoplanin immunohistochemistry could improve LVI detection and allow better prognostication of patients and optimum selection of definitive treatment. Larger multicenter studies are required for further validation that could have significant clinical implications.
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Affiliation(s)
- C Perry
- Division of Oncology, School of Medicine, University of Nottingham, Nottingham, UK
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Cameron GR, Jayasekera CS, Williams R, Macrae FA, Desmond PV, Taylor AC. Detection and staging of esophageal cancers within Barrett's esophagus is improved by assessment in specialized Barrett's units. Gastrointest Endosc 2014; 80:971-83.e1. [PMID: 24929493 DOI: 10.1016/j.gie.2014.03.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/27/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Identification and resection of mucosal abnormalities are critical in managing dysplastic Barrett's esophagus (BE) because these areas may harbor esophageal adenocarcinoma (EAC). OBJECTIVES To compare mucosal lesion and EAC detection rates in dysplastic BE in the community versus a BE unit and assess the impact of EMR on disease staging and management. DESIGN Prospective cohort study. SETTING Tertiary referral center. PATIENTS Patients with dysplastic BE. INTERVENTIONS Reassessment with high-definition white-light endoscopy (HD-WLE), narrow-band imaging (NBI), and Seattle protocol biopsies. EMR performed in lesions thought to harbor neoplasia. Review of referral histology and endoscopies. MAIN OUTCOME MEASUREMENTS Mucosal lesion and EAC detection rates in a BE unit versus the community. Impact of EMR on management. RESULTS Sixty-nine patients were referred (88% male; median age, 69 years). At referral, HD-WLE/NBI use was 57%/14%, and Seattle protocol adherence was 20%. Eighteen patients had intramucosal cancer. Lesions were detected in 65 patients in the BE unit versus 29 patients at referral (P < .001). EMR was performed in 47 patients. BE unit assessment confirmed EAC in all 18 patients and identified 10 additional patients (56% increased cancer detection, P = .036); all 10 had lesions identified in the BE unit (vs 3 identified at referral). EMR in these patients found submucosal cancer (n = 4) and intramucosal cancer (n = 6), resulting in esophagectomy (n = 4) and chemoradiotherapy (n = 1). LIMITATION Academic center. CONCLUSION BE assessment at a BE unit resulted in increased lesion and EAC detection. EMR of early cancers was critical in optimizing patient management. These data suggest that BE unit referral be considered in patients with dysplastic BE.
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Affiliation(s)
- Georgina R Cameron
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Chatura S Jayasekera
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Williams
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Finlay A Macrae
- Royal Melbourne Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Paul V Desmond
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew C Taylor
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
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Alzahrani AM, Bazarbashi SN, Rahal MM, Al-Shehri AS, Aljubran AH, Kandil MS, Zekri JE, Al Olayan AA, Alsharm AA, Yamani NM, Alomary IS, Fagih MA. Saudi Oncology Society clinical management guideline series. Esophageal cancer 2014. Saudi Med J 2014; 35:1545-9. [PMID: 25491227 PMCID: PMC4362166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/13/2014] [Indexed: 02/08/2023] Open
Affiliation(s)
- Ali M Alzahrani
- Oncology Department, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail.
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